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In Defense of The Borg

May 19 will be my sixth anniversary as a Borg drone here at Southwest Hive.

I’m still not fully assimilated. Likely never will be.

I jokingly call my employer The Borg because of their tendency to gobble up smaller ambulance services on the fringes of their territory, relentlessly expanding their empire, like, well, The Borg. And they do have their own unique institutional culture here. They want you to buy in to their approach to EMS and customer service. In fact, they openly refer to it as “The _____ Way.” 

To be sure, a lot of drones have bought in. We’ve got plenty of people who “bleed green,” as they say, and for those people, if it’s not practiced at this company, it might as well not exist in their universe. They think “The _____ Way” is the only way.

Me, I know better. I’ve been around long enough to know shit from Shinola when I smell it. That said, the way they want me to do things is not fundamentally incompatible with my professional ethics.

I’ve worked at other large national ambulance companies – let’s just stick with the Star Trek metaphors and call them “the Ferengi” – where being a good employee and being a good paramedic were fundamentally incompatible.

When I came to work for The Borg, it was a matter of some concern among management types if I’d fit in. I’m a pretty outspoken guy, after all, with a pretty big bully pulpit. People wondered how I’d react when Borg policy ran contrary to the way I think EMS should be done.

It was much worry over nothing, really. I’ve always made it a point to avoid publicly criticizing my employer as long as I’m still cashing their paychecks. Likewise, as long as they pay my salary, I follow their policies. I don’t have to like them, or even pretend they make sense, but I do have to follow them.

That’s one reason I have no desire to be a supervisor drone. There’s a big difference between following a policy, and supporting it. As a supervisor, I’d have a duty to support and enforce those policies. To shirk that duty would make me a hypocrite, and a shitty supervisor, to boot.

Still, The Borg doesn’t really force assimilation down your throat. It is possible here to be a good employee and a good medic. That point was driven home last week in our protocol update class. Some of the changes are timely, some are overdue, and some don’t go far enough in my opinion. But for the most part, they’re positive changes.

And in that protocol class, it was emphasized at least a dozen times, “Use good clinical judgement, and document accordingly.”

As in, “If the protocol says do X, but you believe that is inappropriate due to Y, exercise good clinical judgement and document accordingly.”

That’s all that needs to be said, really. The Borg is far too large to ever be considered clinically progressive – it’s hard to be cutting edge when you have to supervise and QA 2000 medics instead of 20 – but they don’t tie your hands behind your back, either, because of that one critical phrase:

“Use good clinical judgement, and document accordingly.”

I’ve said before that the words shall and must should be purged from EMS protocols, and replaced with may and consider.

May and consider are the two words that empower clinical decision-making. They make your protocols a floor, not a ceiling. That’s been pretty much my MO ever since I became a Borg Drone, and rarely have I been called on the carpet for it. The few times I have, were mostly due to deficiencies in documentation, not questioning my treatment. If I had painted a clearer picture of the patient’s condition and my decision-making process, there wouldn’t have been a problem.

When you’re a new medic, or a mediocre one, you tend to regard your treatment protocols as Holy Writ, and your medical director as an angry and vengeful god, ready to punish you harshly for deviating from The Word.

Obviously, neither is true, although I’ve met a few medical directors who are genuine assholes. Your protocols are treatment guidelines, not suicide pacts, and your medical director is just a guy. He’s a guy with far more medical education and responsibility than you, but generally speaking, he’s on your side, and he expects you to make good decisions in applying the guidelines he wrote.

And if you deviate from them, the good medical directors generally don’t have a problem with it.

Provided, you know, you exercise good clinical judgement and document accordingly.

Comments - Add Yours

  • VinceD

    Great thoughts on knowing your role and playing-nice in the sandbox Kelly! This is something I come up against on a daily basis as a Critical Care Tech and ED tech with training far beyond my pay-grade. While the select few in my Trusted Allies email circle may get the sense that I walk around my work telling off cardiologists and ovary-punching attendings, in reality you’d never keep a job if thought you were beyond protocols and above your role. A little pushback against outdated practice is good because it lets coworkers and supervisors know that their way isn’t the only way, but like you say, it’s got to be smart and it’s got to be supported.

    And on the bright side, sometimes your “new and improved” practice turns out to be wrong, so making a big stink about doing things your way can come back to bite you in the end. For example, my hospital was a bit slow on the uptake for therapeutic hypothermia, and while it killed me at the time I offered only modest nudges towards implementing it and didn’t make a huge deal about our seemingly backwards system (though I wanted to). Now I’m thankful I didn’t make a huge fuss since the literature is backpedaling and I would have been left looking like Chicken Little.

    But apneic oxygenation on the other hand, I’ve been bringing that up during every single intubation we do for years because it’s low-risk and doesn’t cause big drama (though I still can’t get much buy-in).

  • Garrett Kajmowicz

    I’m “merely” an EMT at a small paid/volunteer hybrid service. I am known for finding actual journal articles which impact our service (oftentimes contraindicating current practice), photocopying them and handing them out. I’ll occasionally email or talk with our Medical Director about some of this, too. Occasionally I’ll get a reference to newer/better studies back. Sometimes I’m told “yeah, that violates protocol, but nobody’s going to object as long as you’re reasonable”.
    Knowing how to read and cite actual medical journals/articles goes a long way when dealing with people who use them on a regular basis.

  • http://www.medicmadness.com Sean Eddy

    I know exactly what you mean when you say it’s hard to be cutting edge when you manage 2000 people. I’ve worked for the giant and for the little guys. Both have their ups and downs. Now I’m working for a service that is very forward-thinking in my opinion, but then again, we only have 3 stations, so it’s not hard to keep everyone on the same page.

  • Old_NFO

    Excellent points AD… And PP is learning ‘all’ about that management thingie… And not liking it. Seems whining and complaining are the ‘forte’ of most of the crews, rather than actually DOING EMS…

  • DO

    Are the Borg protocols online?

    • Ambulance_Driver

      No, unfortunately. They’re on our employee intranet, but not publicly viewable.
      Kelly Grayson